EMS, Prehospital Administration Of Thrombolytics For STEMI

Introduction

ST-segment elevation myocardial infarction (STEMI) is a life-threatening, time-sensitive condition that requires prompt recognition, assessment, and treatment. Percutaneous coronary intervention (PCI) and thrombolysis with intravenous thrombolytics are currently available treatments for the restoration of blood flow to affected myocardium. Thrombolysis is an available treatment option for prehospital providers; however, given the risks associated with thrombolytics, care must be taken to identify patients who will benefit without undue risk. With the proliferation of PCI facilities and the regionalization of STEMI care, prehospital thrombolysis is generally a viable option where transport times to PCI or emergency department facilities is prolonged. This activity will review the indications, technique, and requirements surrounding the use of prehospital thrombolytics for STEMI.

Issues of Concern

Feasibility and Safety

Multiple studies evaluated prehospital thrombolysis by EMS personnel.[1][2][3] Currently, the American Heart Association recommends initiation of thrombolytic therapy patients with ischemic symptoms for less than 12 hours when the time from STEMI identification to PCI is greater than 120 minutes barring any contraindications to thrombolysis.[4] One study in rural North Carolina, Crowder, et al. found that prehospital administration of tenecteplase resulted in reperfusion approximately two hours sooner compared to PCI-based strategies and resulted in aborted infarction in approximately 25% of cases. [5] In the same study, 15 (20.5%) patients had serious bleeding, and four patients died (5.5%), similar to prior studies.[1][3] It merits noting that overall 30-day mortality for STEMI ranges from 2.5% to 10%. [6][7][8]

Required Components

The following components are necessary to deliver prehospital thrombolysis for STEMI:

Ability to acquire and prehospital 12 lead electrocardiograms (ECG/EKG)

Support of all invested parties, including receiving facilities and physicians, community partners, and provider

Twelve-lead EKG acquisition is a skill commonly taught to paramedics. Generally, paramedics can interpret 12 lead EKGs to evaluate for STEMI, signs of cardiac ischemia, and rhythm abnormalities. Multiple companies manufacture acquisition devices (which also include continuous cardiorespiratory monitoring and defibrillation capabilities) and generally include interpretation software which can be adjusted by the purchasing agency but not the end-user. This software can aid in the diagnosis of STEMI, and software interpretation may be incorporated into the thrombolysis protocol. While the prehospital interpretation of 12 lead EKGs generally falls to paramedics, acquisition of 12 lead EKGs may be included in the scope of practice of lower-level providers including emergency medical technicians (EMTs) and advanced EMTs (AEMTs).

Generally, physicians must be consulted before administration of thrombolytics to help confirm the diagnosis, ensure patient eligibility, and review checklist criteria. As such, the ability to transmit 12 lead EKGs is crucial for real-time analysis by a physician. With the ubiquity of cellular data networks, the ability to transmit 12 lead EKGs is becoming less complex. Many prehospital cardiac monitors can link wirelessly with a transmitting device such as a smartphone or WiFi hotspot and transmit EKGs directly to a receiving physician. However, rural agencies may not have access to robust late and next-generation cellular networks. Public safety radio networks may be an alternative solution, as well as capturing an image of the EKG printout with a cellular phone and transmitting the image.

The most feared complication of thrombolysis, whether prehospital or in hospital, is severe bleeding. Intracranial hemorrhage is perhaps most feared as it can have devastating outcomes and requires immediate recognition and potential intervention. Other complications, including severe non-intracranial bleeding such as GI bleeding, allergic reaction including anaphylaxis, reperfusion injury or arrhythmia, and hypotension.[9] To help minimize the risk of life-threatening bleeding, a reperfusion checklist is absolutely necessary before the administration of any thrombolytics. The AHA notes that the following are contraindications to thrombolytic administration[4]:

Known intracranial pathology not otherwise specified in absolute contraindications

Traumatic CPR or prolonged CPR for greater than 10 minutes

Major surgery within the last 3 weeks

Recent (within 2 to 4 weeks) internal bleeding

Noncompressible vascular puncture

Pregnancy

Active peptic ulcer

Oral anticoagulant therapy

Using these contraindications as a guide, an EMS system giving prehospital thrombolytics should develop a reperfusion checklist.

Adjunctive therapy is a necessary adjunct with thrombolytics; this includes 162 to 324 mg of oral or rectal aspirin, 300 mg of clopidogrel for patients under or equal to 75 years old (75 mg for patients over 75 years old), and heparin (low molecular weight or unfractionated) or fondaparinux.[4] Nitroglycerin, morphine, and oxygen should also be available for pain relief and treatment of hypoxia. Aspirin, nitroglycerin, morphine, and oxygen are all part of standard prehospital advanced life support therapy for acute coronary syndrome. However, clopidogrel, heparin, and fondaparinux are not likely to be carried by standard ALS units.

For those systems that choose to implement prehospital thrombolysis, destination plans require careful evaluation. Should thrombolysis fail, the patient may require emergent or urgent PCI for rescue therapy. Additionally, patients who suffer adverse reactions to the thrombolytics may require advanced therapies not available at community or rural hospitals. This therapy may include neurosurgical evaluation and treatment, damage control surgery, advanced heart failure therapy, interventional radiology procedures, or other advanced care. Patients who receive prehospital thrombolytics should preferentially get transported to a PCI facility for further management. In very rural situations, this may involve triaging patients who received thrombolytics to be carried by helicopter EMS to a regional facility.

As prehospital thrombolysis is likely a low-frequency intervention, appropriate quality assurance and quality improvement measures are required to maintain competency and ensure appropriate treatment. Doing so involves evaluation of prehospital documentation, including EKGs as well as access to patient outcomes and complications that occurred. Each case should be reviewed to identify areas of improvement.

Finally, all members involved in the care of patients receiving prehospital thrombolytics should support a prehospital program. This healthcare team approach includes hospital administrators, EMS administrators and personnel, emergency department physicians, cardiologists, nursing, pharmacists, and regional or referral facilities who may receive prehospital thrombolysis patients when they suffer an adverse event or other less-than-optimal outcomes. All personnel should be involved in the QA/QI process, and regular feedback should be exchanged to optimize a prehospital thrombolysis program. Only with this type of total interprofessional collaboration can a pre-ICU thrombolytic therapy program undergo successful implementation. [Level V]

Choice of Thrombolytic Agent

Multiple agents exist to achieve thrombolysis. Streptokinase, a non-fibrin specific agent, has largely been replaced by newer fibrin-specific agents. Streptokinase is antigenic and can lead to allergic reactions. It has mostly fallen out of favor for systemic thrombolysis in resource-rich settings and is no longer available in the US, although it should be a consideration for less resource-rich environments.

Fibrin-specific agents include tenecteplase (TNK-tPA), reteplase (rPA), and alteplase (tPA). They are not antigenically compared and are generally safer than streptokinase regarding bleeding complications. Tenecteplase can be given as a single IV bolus based on weight while reteplase requires two boluses 30 minutes apart with fixed dosing. Alteplase is dosed based on weight and requires a 90-minute infusion which requires the use of an IV pump. Tenecteplase is more specific for fibrin with reteplase and alteplase being less specific. All deliver similar thrombolysis.[4] Alteplase, reteplase, and tenecteplase can be stored at room temperature or under refrigeration before reconstitution. Cost is a significant factor for all thrombolytic agents, and availability and price can play a large part in determining which agent an agency may use. Expired medication is a concern given that prehospital fibrinolysis may be a low-frequency occurrence.

Clinical Significance

Overall, prehospital thrombolysis can dramatically reduce the time to restoration of blood flow to myocardium suffering from STEMI. The ER-TIMI trial demonstrated that STEMI patients receiving fibrinolytic therapy in the prehospital setting received said therapy 32 minutes sooner than similar patients who received said therapy in the hospital.[1] A meta-analysis in 2000 by Morrison, et al. found that prehospital thrombolysis decreased time to thrombolysis and all-cause hospital mortality.[10] Similar findings were noted in 2006 by Welsh et al., in an urban setting.[3] A Cochrane review in 2014 supported prehospital thrombolysis. However, it pointed out that the majority of data collection was in relatively resource-rich locations, including the US and Europe.[11] French investigators noted that patients treated with prehospital thrombolysis had higher one-year survival compared to those who received hospital-based thrombolysis or PCI.[2] While this data is encouraging, it is worth noting that the occurrence of STEMI that is amenable to prehospital thrombolysis may be relatively infrequent; the Cincinnati Heart Project and the Nashville Prehospital TPA trial found this incidence to be approximately 5%.[12] As such, the financial implications of implementing a prehospital thrombolysis protocol should be a consideration. However, in a review of the treatment of rural STEMIs in Norway over 11 years, it was noted that prehospital thrombolysis rates increased over time, as did the number of patients receiving PCI within 24 hours. Prehospital thrombolysis was noted to save 131 minutes per patient. Incidents of reperfusion heart failure decreased in that time. Mortality trended downward, and bleeding complications remained stable.[13]

Prehospital thrombolysis can improve STEMI to reperfusion times and mortality. Serious consideration is necessary regarding all available resources, local populations, and QA/QI processes prior to implementing a prehospital thrombolysis program.